The impact of functional status on LOS and readmission in older patients in geriatrics department: a cohort study.

BACKGROUND: Length of hospital stay (LOS) and readmission are important outcomes for older inpatients. The association between functional status on admission and outcomes has not been well investigated in Chinese elderly. OBJECTIVES: To detect the impact of function impairments on LOS and 90-day readmission in a population of Chinese elderly inpatients. METHODS: This is a prospective cohort study. All new patients over 60 years in geriatrics department of a university hospital in Western China from June to August 2016 were enrolled. Activities of daily living (ADL) and Instrumental ADL (IADL) on admission were evaluated with Barthel Index and Lawton IADL. Outcomes were LOS and 90-day readmission. LOS was calculated as the total days of hospital stay. Readmission was investigated through telephone interviews after discharge. Pearson Chi-square test was used to detect the associations. Binary logistic regression was used to detect the association of function status on admission with LOS and readmission. RESULTS: A total of 225 patients were enrolled. Mean age 82.41 (± 7.316; 63-99), 31.1% were females. Overall, 64.9% of the patients were hospitalized longer than 14 days and 33.30% experienced a 90-day readmission. Following an adjustment for age, gender, marital status, education level, smoking, alcohol, nutrition status, and admission location, the binary logistic regression models showed that both ADL impairment (OR 2.03; 95% CI 1.06-3.87) and IADL impairment (OR 2.54; 95% CI 1.28-5.01) were independent predictors for LOS. ADL impairment was an independent predictor for 90-day readmission (OR 2.26; 95% CI 1.14-4.47), while IADL impairment was not associated with readmission (OR 1.43; 95% CI 0.68-3.02). CONCLUSION: Functional status on admission is the predictor of LOS and 90-day readmission in Chinese older inpatients from the geriatric department of a university hospital.

Use of an expert panel to identify domains and indicators of delirium severity.

PURPOSE: Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity. METHODS: We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better ASsessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one-month period, experts participated in two rounds of review. RESULTS: Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of consciousness, Inattention, Psychiatric-Behavioral, Emotional dysregulation, Psychomotor features, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations. CONCLUSIONS: We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

Refining Delirium: A Transtheoretical Model of Delirium Disorder with Preliminary Neurophysiologic Subtypes.

The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.

Comparison of procalcitonin, a potentially new inflammatory biomarker of frailty, to interleukin-6 and C-reactive protein among older Chinese hospitalized patients.

AIM: Procalcitonin (PCT) has predictive value for patients with infectious diseases, but has not been studied in frailty. The purpose of this study was to compare PCT to two other inflammatory biomarkers [interleukin-6 (IL-6)] and C-reactive protein (CRP) in their association with frailty among older hospitalized patients. METHODS: Retrospective study of inpatients (June-December, 2016), who had all three biomarkers measured within 24 h of admission. Frailty was defined according to the Chinese version of a validated frailty scale. Due to the association of biomarkers with infection, we divided patients into "non-infected" (no pneumonia or other infections) and "pneumonia" (using standard criteria) groups. RESULTS: Of 435 patients (mean age 81.6 ± 8.6 years), 181 (41.6%) were designated the non-infected group and 254 (58.4%) the pneumonia group. Prevalence of frailty in the non-infected group was 32.0% (58/181) and frailty (univariate analysis) was associated with higher PCT and IL-6 levels but not CRP. Prevalence of frailty in the pneumonia group was 40.2% (102/254) and frailty was associated with all three biomarkers. In multivariable analysis adjusting for age, gender, smoking, alcohol use, hemoglobin, albumin, neutrophils and creatinine, PCT (not IL-6 and CRP) was associated with frailty in the non-infected group (OR = 5.244; 95% CI, 1.622-16.947; P = 0.006) and none of the biomarkers were associated with frailty in the pneumonia group. CONCLUSIONS: Although the study is limited due to the retrospective methods, PCT but not IL-6 or CRP, was associated with frailty among older inpatients without infection. None of these biomarkers were associated with frailty among patients with pneumonia.

Do nutrients play a role in delirium?

PURPOSE OF REVIEW: This study will review the biologic roles of thiamine, niacin, folic acid, cobalamin, antioxidants, lipids, glucose, and water and their implications as contributors or causal agents in the development of delirium, particularly if deficiencies or excesses exist. RECENT FINDINGS: Knowledge on how overall nutritional status and individual nutrients predispose or directly lead to the development of delirium is currently very limited. Most studies in the area of nutrition and cognition still describe mental status changes using the term dementia and do not specifically address nutrition and delirium. However, as the brain pathophysiology that accompanies delirium has been furthered elucidated, it has become clear that nutritional imbalances can lead to these same physiologic changes in neuronal tissue. SUMMARY: Delirium, characterized by an acute change in mental status along with diminished awareness and attention and disturbances in memory, language, or perception, confers high rates of morbidity and mortality and can be difficult to both diagnose and treat. Although the cause of delirium is often multifactorial, nutritional status and nutrients may play a role in predisposing or directly causing this acute cognitive dysfunction. Many nutritional deficiencies or excesses (i.e., B vitamins, antioxidants, glucose, water, lipids) have been shown to alter the way one thinks and restoring the balance in many of these nutrients can lead to resolution of delirium.

Delirium in the elderly.

Delirium is an acute and common problem often affecting frail and older persons in the acute care hospital, but can develop in any setting. It is associated with serious complications but can also be treatable if diagnosed early and managed properly. Preventive measures should be implemented in high risk patients, such as those with malnutrition, polypharmacy, infections, previous delirium, or dementia. Despite precautions, delirium is unavoidable in some cases and clinicians should be familiar with the typical features and varied presentations of this condition. Diagnosing delirium can be based on the DSM criteria, though multiple useful screening tools exist. Since delirium is almost always triggered by an underlying condition, an aggressive search for the causative insult(s) is essential in order that a targeted intervention be started promptly. Although there is neither any medication approved by the FDA for the treatment of delirium nor any robust evidence supporting the benefit of medications, there is general consensus that drug intervention can be attempted when non-pharmacological interventions have failed.

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States.

Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

Association between body mass index and cognitive function among Chinese nonagenarians/centenarians.

AIMS: We examined the individual association between body mass index (BMI) and cognitive function among the very elderly. METHODS: The present study analyzed data from a survey that was conducted on all residents aged 90 years or more from a district which had 2,311,709 inhabitants in 2005. The subjects were divided into 4 groups according to quartiles of BMI (<16.6, 16.6-18.9, 18.9-21.1 and >21.1), and according to classification criteria of underweight, normal weight, overweight and obesity in BMI (<18.5, 18.5-23.0, 23.0-27.5 and >27.5), respectively. RESULTS: The subjects included in the statistical analysis were 211 men and 427 women. Those in the 3rd quartile of BMI (18.9-21.1) had higher cognitive function scores (p < 0.001) and were less likely to present possible dementia (p = 0.016) than the others. However, there was no difference in cognitive function scores (p = 0.350) or prevalence of possible dementia (p = 0.263) among obesity, overweight, normal weight and underweight groups. CONCLUSIONS: Concerning longevity in Chinese, there is an association between BMI and cognitive function. BMI of around 20 (18.9-21.1) is associated with the lowest risk of prevalence of possible dementia and the highest cognitive function scores.

Association of cognitive impairment with serum lipid/lipoprotein among Chinese nonagenarians and centenarians.

The association of cognitive impairment with abnormal levels of serum lipid/lipoprotein in the elderly, in whom there are differences between the old aged 65-84 years and the oldest old aged 85 years or above, has been confirmed by previous studies. However, there are no relevant data from a Chinese oldest old population. In the present study, we observed an association of cognitive impairment with abnormal levels of serum lipid/lipoprotein among very old people using a Chinese cohort aged 90-108 years. The population included 709 unrelated Chinese nonagenarians and centenarians (67.8% women, mean age 93.8 years). The mean score of cognitive function (measured with the 30-item Mini-Mental State Examination, MMSE) was 14.9 (SD 6.0). Comparing abnormal with normal levels of serum lipid/lipoprotein (including triglycerides, total cholesterol, high-density lipoprotein and low-density lipoprotein), in both genders, the odds ratio of cognitive impairment was statistically insignificant. There were no significant differences in levels of lipid/lipoprotein between subjects with and without cognitive impairment. Pearson correlation showed that MMSE scores were not significantly correlated with levels of lipid/lipoprotein. In summary, we found that levels of serum lipid/lipoprotein were not directly correlated with cognitive impairment among Chinese nonagenarians and centenarians.

Insomnia among hospitalized older persons.

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

Transformation of a Geriatric Department in China.

China has the world's largest elderly population, and the oldest-old population, with a current disability rate greater than 50%, will triple in the next 35 years. The field of geriatrics is young, because almost all geriatric departments were established after 2000, and so faces many challenges. Management of diseases and hospital care is the focus. Senior physicians were trained in other subspecialties, such as pulmonary or cardiology, and junior physicians entered geriatrics departments as masters or doctorate students after medical school. The inadequacy of post-acute and long-term care facilities has caused long hospital stays. There are no national systematic geriatric training programs, national board examinations, or qualifications in geriatrics. These challenges were used as a framework for guiding changes in the Department of Geriatrics at West China Hospital, Sichuan University. These changes have included international experiences and collaboration for physicians and nurses, revision of departmental conferences, and special training for a unique group of caregivers called hugong (untrained caregivers hired by families to be at the bedside of hospitalized individuals). The most significant yet challenging part of the transformation has been to develop and modify Western-based geriatric models of care (e.g., Acute Care of the Elderly unit, delirium prevention and management models, palliative care). Lastly, the department established Tianxia (in the sky) Doctors, an internet-based platform to connect the department's interdisciplinary team to other hospitals, nursing institutions, home-based care service stations, community health service centers, and pharmacies throughout the region.

Debating the Role of Arousal in Delirium Diagnosis: Should Delirium Diagnosis Be Inclusive or Restrictive?

Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.

Dissecting Delirium: Phenotypes, Consequences, Screening, Diagnosis, Prevention, Treatment, and Program Implementation.

Delirium is an acute change in attention and awareness that preferentially occurs in older patients with acute illness. This review provides an overview for clinicians with descriptions of the presentations (phenotypes), consequences, diagnosis, and screening of delirium. In addition, this review provides guidance for the challenges posed by delirium in a health care system, including implementation of delirium programs, tools to address the diagnosis and differential diagnosis of delirium, and a review of preventive and treatment studies with a goal of improving clinical practice.

The incidence of delirium after cardiac surgery in the elderly: protocol for a systematic review and meta-analysis.

INTRODUCTION: Delirium is one of the most common complications after cardiac surgery in the elderly. Future studies aimed at preventing postoperative delirium will need an accurate estimate of incidence. However, there are no available systematic reviews on the incidence, and reports of incidence of postoperative delirium after a cardiac operation vary widely with significant heterogeneity. Therefore, we aim to perform a systematic review and meta-analysis to determine the most accurate incidence possible of postoperative delirium in individuals aged >65 years after cardiac surgery. METHODS AND ANALYSES: We will undertake a comprehensive literature search among PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL, from their inception to January 2017. Prospective cohort and cross sectional studies that described the incidence of delirium will be eligible for inclusion. The primary outcome will be the incidence of delirium. Risk of bias and methodological quality for the included studies will be assessed using a risk of bias tool for prevalence studies and the Cochrane guidelines. Heterogeneity of the estimates across studies will be assessed. Incidence data will be pooled by selective or emergency surgery. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). ETHICS AND DISSEMINATION: This proposed systematic review and meta-analysis is based on published data, and thus there is no requirement for ethics approval. The study will provide an up to date and accurate incidence of postoperative delirium among the older population after cardiac surgery, which is necessary for future research in this area. The findings of this study will be presented at conferences and disseminated through publication in a peer reviewed journal. TRIAL REGISTRATION NUMBER: CRD42016047773.

Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial.

IMPORTANCE: Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. OBJECTIVE: To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS: This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. INTERVENTIONS: Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. MAIN OUTCOMES AND MEASURES: The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. RESULTS: In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201], P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. CONCLUSIONS AND RELEVANCE: Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. TRIAL REGISTRATION: clinicaltrials.gov Identifier NCT00561678.

Antioxidants and hormones as antiaging therapies: high hopes, disappointing results.

No single agent has been shown to truly reverse aging or increase longevity in humans. This article reviews the evidence of efficacy (or lack thereof) for two types of agents touted as antiaging therapies: antioxidants (vitamin E, vitamin C, and carotenoids) and hormones (growth hormone, testosterone, dehydroepiandrosterone, and vitamin D).

Elder abuse and neglect in long-term care.

Patient and caregiver education and other interventions targeted toward risk factors or types of abuse or neglect play an invaluable role in preventing elder abuse and mistreatment.

Brain health: the importance of recognizing cognitive impairment: an IAGG consensus conference.

Cognitive impairment creates significant challenges for patients, their families and friends, and clinicians who provide their health care. Early recognition allows for diagnosis and appropriate treatment, education, psychosocial support, and engagement in shared decision-making regarding life planning, health care, involvement in research, and financial matters. An IAGG-GARN consensus panel examined the importance of early recognition of impaired cognitive health. Their major conclusion was that case-finding by physicians and health professionals is an important step toward enhancing brain health for aging populations throughout the world. This conclusion is in keeping with the position of the United States' Centers for Medicare and Medicaid Services that reimburses for detection of cognitive impairment as part the of Medicare Annual Wellness Visit and with the international call for early detection of cognitive impairment as a patient's right. The panel agreed on the following specific findings: (1) validated screening tests are available that take 3 to 7 minutes to administer; (2) a combination of patient- and informant-based screens is the most appropriate approach for identifying early cognitive impairment; (3) early cognitive impairment may have treatable components; and (4) emerging data support a combination of medical and lifestyle interventions as a potential way to delay or reduce cognitive decline.

A model for managing delirious older inpatients.

Although multiple models of care exist to prevent the development of delirium in hospitalized patients, models for the management of patients for whom delirium is unpreventable or who already have delirium on admission to the hospital are needed. This article describes the development, management, and economics of a new model of care for patients with delirium, called the Delirium Room (DR). The DR is a specialized 4-bed unit that provides 24-hour intensive nursing care and is completely free of physical restraints. Another important feature of the 4-bed DR is that it is an integral part of a 22-bed acute care for the elderly (ACE) unit. As such, patients in the DR benefit from features of the ACE unit: a change in the physical environment of the medical floor to promote mobility and function and discourage bedrest, comprehensive geriatric care that identifies and addresses problems that can lead to a decline in function, and use of a daily multidisciplinary team meeting. This article also presents descriptive data on a group of delirious patients managed in the DR with the intention of giving baseline data for other ACE units that are considering opening a DR or for future prospective studies in this area.